A 72-year-old woman presented with symptoms of acute eye pain, headache, blurred vision, nausea, and vomiting. Visual acuity was hand motions in the affected eye. The cornea had diffuse bullous edema and the anterior chamber was flat peripherally. The IOP was 56 mmHg. A diagnosis of acute angle-closure was made. The patient did not respond to standard medical therapy; the cornea was too edematous to perform laser iridotomy, pupilloplasty, or peripheral iridoplasty. A paracentesis only transiently lowered the intraocular pressure and did not appreciably clear the cornea. Surgical iridectomy was performed on an urgent basis following pretreatment with IV osmotics. Postoperatively the chamber deepened centrally and peripherally and the angle was shallow but open on gonioscopy. The vision returned to 20/80 and the cornea cleared. The lens had moderate nuclear sclerosis and cortical opacity with glaukomflecken. The intraocular pressure fell to 18 mmHg. Five days later the patient returned with complaints of mild discomfort. Visual acuity was 20/200. The cornea was clear. The anterior chamber was flat peripherally and centrally. The surgical iridectomy was patent and the intraocular pressure was 38 mmHg (Fig. 15.1). There were no suprachoroidal effusions or hemorrhages detectable by ophthalmoscopy, B-scan ultrasound, or UBM. Based upon the findings, a diagnosis of classic malignant glaucoma was made (see Table 15.3). Intensive medical therapy was instituted (see section “Medical Treatment”), and over the next several days, the chamber slowly deepened and the pressure returned to 21 mmHg. The patient subsequently underwent uncomplicated cataract extraction with posterior chamber IOL with no recurrence of malignant glaucoma. The visual acuity with correction returned to 20/25. The presence of a moderate amount of peripheral anterior synechia necessitated chronic medical therapy for secondary angle closure to maintain an IOP of 15 mmHg.

A 38-year-old woman with a history of uveitis and glaucoma developed a secluded pupil with pupillary block and iris bombé. This was relieved by surgical sector iridectomy. The IOP was initially managed medically but subsequently required trabeculectomy. On the third postoperative day, the bleb collapsed and the anterior chamber flattened both peripherally and centrally with an IOP of 24 mmHg (Fig. 15.2). A diagnosis of classic malignant glaucoma was made based on the presentation and the diagnostic findings (see Table 15.3). The patient did not respond to intensive medical therapy (see section on “Medical Treatment”) and vitrectomy was performed (see section on “Surgical Therapy”). Postoperatively the chamber deepened and the pressure was controlled on medical therapy.

Elevated IOP and shallowing of the chamber can occur during the surgery, immediately afterward, after the discontinuation of cycloplegics [9], after the initiation of miotics [9, 11], or quite some time later [11–15]. If one eye develops malignant glaucoma after surgery, the contralateral eye will probably do likewise. Although the IOP may in some cases be in the teens to low twenties following filtration surgery, it may at times be 40–60 mmHg or greater. Miotics are ineffective in lowering IOP and instead may further increase the pressure. Conventional filtering surgery in patients who have had previous peripheral iridectomy does not reverse the problem.